Ischemic Stroke - Hennepin County Medical Center

Case Reports
Since this patient suffered a relatively small
area of already infarcted brain prior to the procedure,
his risk of suffering a hemorrhage was
probably significantly lower than one might
predict based on the treatment time window.
Figure One. On left, occlusion of left MCA. On right, reperfusion after IAT.
received IAT within 6 hours of MCA stroke
symptom onset with a control group that
received IV heparin. IAT succeeded in arterial
recanalization of 67% of patients vs. 18% in
the control group.
The possible side effect of intracerebral hemorrhage
(ICH) remains a concern. In this
PROACT II study, there was an increase in
symptomatic ICH (10.2% vs. 1.8% at 24
hours), although there was no significant difference
in 90-day survival. Less data are available
comparing IAT to IVT. Further studies of
IAT for MCA ischemic stroke are needed
before approval of this treatment by the FDA.
In this case, the patient presented after the traditionally
accepted window for both IVT and
IAT. There is limited research on delayed IAT
administration, but recent data suggest that
IAT administration based on imaging and
symptoms can extend the accepted treatment
window. One study of intra-arterial urokinase
administered within 3.5 to 48 hours of symptom
onset in 13 patients showed symptom
improvement in 69% of patients at 48 hours
and 100% of surviving patients at 3 months.
This patient may have been considered a good
candidate for delayed IAT because he was
young, otherwise healthy with few co-morbidities,
and had a CT perfusion scan and MRI
scan that showed only a small existing infarction
with a very large perfusion deficit (i.e.
large ischemic penumbra.) New data also suggest
that the risk of symptomatic intracerebral
hemorrhage related to thrombolysis correlates
with the size of the infarction prior to treatment.
Suggested Readings/Bibliographies for Case Reports
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10 | Approaches in Critical Care | December 2008